Laparoscopic Gastric Bypass with Roux Y Limb

A Standard or Long (120cm) is used to create the pneumo-peritoneum. We favor the sub-umbilical position.

The trocars are inserted as shown. The intra-abdominal cavity is explored.

The surgeon will check the omentum is free of adhesions ( pelvis).  The omentum is then retracted toward the upper portion of the intra-abdominal cavity as the operating table is tilted in Trendelenbourg Position (Head down). A  Mediflex® 5 mm Retractor is inserted and locked in place (using the MEDFLEX® Retractor or the ENDORETRACT®) retracting the omentum cephalad while simultaneously exposing the ligament of Trietz.

The ligament of Treitz is located. The jejunum is transected 30cm from the ligament of Treitz with the ENDOGIA II UNIVERSAL INSTRUMENT ®(loaded with a 60 mm white or blue cartridge). Long graspers are used to present the jejumun between the limbs of the stapling device .

The stapling device should be fired at right angle with the jejunum.  Hemoclips® are used to control the bleeding at the transected sites or on the staple lines. The vascular supply of the ends of the jejunal limbs should be checked (specially at the stapled corners).  Be absolutely sure of the orientation of the jejunal limbs.  The stapled tip of the Roux Y Limb is advanced and the limb placed in right lateral position.

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Seventy five to one hundred centimeters from the end or tip of the Roux Limb is measured (an open bowel grasper is used to measure the length of the limb). 

At this site, the two jejunal  limbs are approximated with a 0 Soft-silk ® suture ( using the ENDOSTICH ® DEVICE ) and aligned. The tip of the proximal corner of the stapled jejunum and the anti-mesenteric border of the distal limb are opened with the ULTRASHEARS ® INSTRUMENT  (two enterotomies are created to introduce the jaws of the ENDOGIA II UNIVERSAL INSTRUMENT ®). 

The ENDOGIA II UNIVERSAL INSTRUMENT ® (loaded with a 60 mm white or blue cartridge) is inserted and fired. Using the ENDOSTICH  ® INSTRUMENT,  a suture is placed at mid aspect of the newly created enterotomy thus aligning and "triangulating" it. The two corners of the open anastomosis are grasped and closed with an ENDOGIA II  ® UNIVERSAL INSTRUMENT(with 60 cartridge).  Always check the caliber of the anastomosis.  Unfold and straighten the Roux Limb.

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If a retro-colic-gastric Roux Limb position is selected a Penrose ¼ inch drain is inserted in the intra-abdominal cavity and is sutured to the end of the Jejunal Roux Limb with an ENDOSTICH ® INSTRUMENT. 

The mesenteric defect under the jejuno-jejunal anastomosis is closed with a running suture of 0 Soft-Silk suture using the ENDOSTICH  ® INSTRUMENT.

At this time, the surgeon has the choice to place the Roux Limb in Retro-colic-gastric position or in ante-colic postion. We use the retro-colic-gastric placement for super-obese patients or patients with a large, bulky omentum. Otherwise, an anti-colic position is selected as it it a faster technique.

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If the Roux Limb is placed in ante-colic position, this technical step is omitted. An entry site into the lesser sac should be identified. The mesocolon is held toward the abdominal wall and an incision is made with the ULTRASHEARS ® INSTRUMENT or the ETHICON HARMONIC DEVICE ®  immediately above (2 cm) the ligament of Treitz on the mesocolon. The surgeon should carefully  identify and avoid any significant large-bore blood vessels. The thickness of the mesocolon is only 1 to 1,5 cm. This dissection should be blunt until the retro-gastric space is entered.

When entered, the Penrose drain is pushed as high and cephalad as possible and the Roux Limb is placed at the entry of the tunnel. Check again that the Roux Limb is not twisted.

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A BIOENTERIC ®  Gastric tube is inserted trans-orally into the stomach. The intra-gastric balloon is inflated with 30 cc of normal saline and pulled back by the anesthesiologist under direct vision until resistance is met (at the level of the Gastro-esophageal Junction). The intra-gastric balloon is then deflated to a 10 cc capacity. The location of the gastro-esophageal junction and the site of the future gastric transection are verified.

Initiating the transection of the stomach is a difficult maneuver for the inexperienced surgeon as significant injuries to major blood vessels can occur and significant blood loss can be generated. To avoid such injuries, a clear path to the retrogastric space from the lesser curvature is identified .

The retrogastric space or lesser sac is dissected by creating an entry tunnel below the second gastric vascular arcade with a blunt grasper.

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The stomach is transected with ENDOGIA II ® UNIVERSAL INSTRUMENT  (using 60 cm 3.5 cartridges) from the lesser curvature  toward the upper part of the fundus between the spleen and gastro-esophageal junction (loaded with a blue cartridge). The intra-gastric balloon is removed.

The staple lines are not reinforced.

The gastric pouch is turned upward exposing the posterior wall. The inferior body of the stomach is retracted laterally.

For Roux limb in retro-colic-gastric position, the Penrose Drain is located and the Roux Y Limb is pulled effortlessly  next to the newly created gastric pouch. It is verified the gastro-enterostomy to be created will be without tension. To do so, in some cases the gastro-enterostomy may have to be created 10 to 15 cm from the tip the the limb.

The ULTRASHEARS  ® INSTRUMENT or the ETHICON Harmonic Device  is used to create an enterotomy (on the antimesenteric side). A gastrotomy is also created with the same instrument ( 1.5 cm from the gastric staple line) on the posterior wall of the gastric pouch.

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It is essential to identify the transected gastric mucosa  in the gastrotomy (a full thickness gastrotomy should be performed). The ENDOGIA II ® UNIVERSAL INSTRUMENT (loaded with a  blue 60 or 45 mm cartridge) is inserted and the two jaws of the stapling device are inserted in the enterotomy and the gastrotomy. The ENDOGIA II ® UNIVERSAL INSTRUMENT is fired for a length of 30 mm (check the scale marking on the side of the cartridge) to make a small, calibrated gastro-enterostomy. The stapling device is then withdrawn. 

The gastric balloon and tube is advanced by the anesthesiologist and guided through the open gastro-enterostomy into the Roux Limb. It will be used to further calibrate the gastro-enterostomy to a perfect, reproducible, universally sized gastro-enterostomy. Experienced surgeons can calibrate of the gastro-enterostomy by calculating the length of the firing of the ENDOGIA cartridge [use the measuring scale on the side of the stapling cartridge].

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The ENDOSTICH ®  INSTRUMENT is used to place two (or three) sutures at each end of the anastomosis (and in the middle) to approximate and "triangulate" the last portion of the anastomosis to be closed. The ENDOGIA II ® UNIVERSAL INSTRUMENT is inserted with a white-or-blue 60 mm cartridge (a roticulator cartridge may be necessary). 

Using the previously placed sutures, the area to be stapled is presented into the jaws of the stapler. The ENDOGIA II ® UNIVERSAL INSTRUMENT is closed and fired . 

In most cases (91%), it is too difficult and unsafe to complete and close the gastro-enterostomy [anteriorly] with a stapling device . It should be closed and completed with interrupted 0 Soft-silk interrupted suture using the ENDOSTICH ® INSTRUMENT.

The entire upper portion of the intra-abdominal cavity is filled with normal saline, immersing the entire gastro-enterostomy. The Roux an Y limb is occluded distally with an bowel clamp. An nasogastric  tube is inserted under direct vision into the gastric pouch. The gastric pouch is then filled with air under pressure (using a 60 cc catheter tip syringe). The surgeon will simultaneously check for the presence of an air leak.

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For Roux Limb in retro-colic-gastric position, the surgeon will anchor the Roux Limb on the mesentery around the Roux Limb going into the retro-gastric retro-colic tunnel with  two 0 Silk Sutures.

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A Blake™ drain is placed around the gastro-enterostomy. The abdomen is deflated. The trocars are removed.